Provider Demographics
NPI:1265529150
Name:HOLDREGE FAMILY VISION CLINIC PC
Entity type:Organization
Organization Name:HOLDREGE FAMILY VISION CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRES
Authorized Official - Prefix:
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:E
Authorized Official - Last Name:QUINCY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:308-995-8697
Mailing Address - Street 1:503 MCMILLAN STREET
Mailing Address - Street 2:PO BOX 920
Mailing Address - City:HOLDREGE
Mailing Address - State:NE
Mailing Address - Zip Code:68949-0920
Mailing Address - Country:US
Mailing Address - Phone:308-995-8697
Mailing Address - Fax:
Practice Address - Street 1:503 MCMILLAN STREET
Practice Address - Street 2:
Practice Address - City:HOLDREGE
Practice Address - State:NE
Practice Address - Zip Code:68949-0920
Practice Address - Country:US
Practice Address - Phone:308-995-8697
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2009-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE831332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND0269890002OtherNORIDIAN DMERC
NE=========13Medicaid
NE=========13Medicaid
ND0269890002OtherNORIDIAN DMERC
NE094151Medicare ID - Type UnspecifiedGROUP NUMBER